Optimizing surgical strategy in Lenke 5C AIS patients with poor thoracic compensatory ability: is there a role of coronal imbalance?

Optimizing surgical strategy in Lenke 5C AIS patients with poor thoracic compensatory ability: is there a role of coronal imbalance? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Optimizing surgical strategy in Lenke 5C AIS patients with poor thoracic compensatory ability: is there a role of coronal imbalance? Chunxiao Chen, Qiang Liu, Jie Li, Xiaodong Qin, Benlong Shi, Saihu Mao, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8548158/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Apr, 2026 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted 12 You are reading this latest preprint version Abstract Purpose To investigate the effect of preoperative coronal balance patterns on the clinical outcome of Lenke 5C patients with poor thoracic curve compensation ability following different fusion strategies. Methods Poor thoracic compensatory ability was defined as a thoracic cobb angle between 15° and 25° on supine bending films. Coronal balance patterns were classified as Type A (coronal balance distance [CBD] 20 mm and C7 plumbline[C7PL] shifted to concave side of main curve), and Type C (CBD > 20 mm and C7PL shifted to convex side of main curve), based on CBD and position of C7PL relative to main curve. Patients with preoperative Type C were classified into the Group Type C1(underwent selective fusion) and the Group Type C2(underwent non-selective fusion), and patients with preoperative Type A all underwent selective fusion surgery. Quality of life in preoperative Type C patients following different fusion strategies was assessed using the SRS-22 scale. Results Patients with preoperative Type C coronal pattern and poor thoracic compensatory ability showed a higher likelihood of thoracic curve progression after selective fusion surgery compared to Type A patients (48.7% vs. 20.9%, P = 0.007). In the Type A group, only 4.65% experienced thoracic curve progression exceeding 10°, while in the Type C1 group, this percentage was 21.95%. Additionally, at the last follow-up, 93.1% of Type A patients maintained good coronal balance, whereas 17.1% of Type C1 patients still had coronal imbalance. Type C2 patients who underwent non-selective fusion showed improved thoracic curvature from 34.86 ± 4.64° to 11.14 ± 4.30°, which was well maintained during follow-up. At the last follow-up, only 1 of 35 (2.8%) patients retained the Type C coronal pattern. The SRS-22 questionnaire showed that in Lenke 5C AIS patients with preoperative Type C, the Type C2 group had significantly higher pain (4.33±.51 vs. 3.87±.55, P = 0.003) and self-image scores (4.88±.10 vs. 4.55±.50, P = 0.020) compared to the Type C1 group. Conclusion For Lenke 5C AIS patients exhibiting poor thoracic compensatory ability and preoperative Type C coronal imbalance, selective fusion demonstrated higher risks of proximal thoracic curve progression compared and inferior coronal balance restoration during follow-up. These findings suggest cautious consideration for preoperative coronal pattern and poor thoracic compensatory ability in Lenke 5C AIS patients when planning surgery strategies. adolescent idiopathic scoliosis Lenke 5C thoracic progression coronal imbalance surgical strategy Introduction In the surgical management of Lenke 5C adolescent idiopathic scoliosis (AIS), selective fusion is favored to maximize spinal mobility, and the unfused curve could be spontaneously corrected postoperatively since the good flexibility of thoracic curve. [1–3] While Kwan [4] found that Lenke 5 + patients (thoracic Cobb angle > 15° on supine bending films) exhibit similar thoracic compensatory ability to Lenke 6, suggesting non-selective fusion for Lenke 5 + AIS. Although study [5] indicated that patients with limited thoracic curve compensation can achieve spontaneous correction after selective fusion and maintain good long-term quality of life, the correction rate of thoracic curve is unsatisfactory. Furthermore, the evolution of the non-fused thoracic curve in patients over extended follow-up periods is not well understood. Consequently, there is a need for further research to determine the optimal fusion strategy for Lenke 5C AIS patients with poor thoracic compensatory ability. Coronal imbalance remains a frequent postoperative complication in Lenke 5C AIS patients, impacting their appearance and satisfaction after surgery, and severe imbalance may necessitate revision surgery. Literatures indicated that 6.9% to 17.4% of Lenke 5C patients who underwent selective thoracolumbar/lumbar curve fusion experienced coronal imbalance during follow-up. [6,7] Although several risk factors for persistent coronal imbalance (PCI) such as a larger L5 tilt, LIV tilt > 25°, selection of L5 as LIV, poor thoracic curve flexibility, larger preoperative AVT–TL/L, and immediate postoperative coronal imbalance had been reported [8–11] , clinicians are constantly exploring how to improve the postoperative coronal balance. The recent research [12] found that Lenke 5C patients with preoperative coronal pattern of Type C (coronal balance distance [CBD] > 20 mm and C7 plumbline[C7PL] shifted to convex side of main curve) had suboptimal coronal restoration following selective fusion surgery, resulting in 29% remaining coronal imbalance at the last follow-up. This highlights the importance of considering the preoperative coronal patterns' impact on postoperative coronal balance restoration when planning surgical interventions. While non-selective fusion more effectively improves coronal deformity, correcting thoracic curve and controlling its progression, it may decrease the thoracic kyphosis and clinical flexibility. Clinicians need to plan surgical strategies based on patients' conditions to achieve maximum benefits. Such as previous study had suggested that Lenke 5C AIS patients with thoracic kyphosis are more suitable for non-selective fusion surgery. [13] While few studies analyzed the impact of poor thoracic coronal compensation ability and preoperative coronal pattern on clinical efficacy following different fusion strategies. This study aims to: (1) evaluate the clinical outcomes of Lenke 5C patients with different preoperative coronal balance patterns and poor thoracic coronal compensation ability after selective thoracolumbar/lumbar fusion; (2) compare the clinical outcomes of Lenke 5C patients with preoperative coronal Type C and poor thoracic coronal compensation ability undergoing different fusion strategies. We hypothesized that Lenke 5C patients with preoperative coronal Type C and poor thoracic compensatory ability may benefit more from non-selective fusion compared with selective fusion. Methods Subjects This is a retrospective cohort study that was performed for AIS underwent posterior spine fusion surgery from March 2012 to February 2023. The main inclusion criteria were about (1) clinical diagnosis as Lenke 5C AIS patients; (2) poor thoracic compensation ability, defined as thoracic cobb angle on supine bending film between 15 and 25° preoperatively [4] ; (3) followed up at least 2 years; (4) complete preoperative, postoperative and follow-up clinical data. The exclusion criteria were as follows: (1) patients with previous surgery related to spine, pelvis and lower extremities; (2) spinal deformities with definite etiology, such as tumor, congenital scoliosis and neurogenic scoliosis. This study was approved by the Institutional Review Board (IRB) of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (IRB No. 2021-398-01). Data collection and measurement The demographic data, including age, gender, Risser sign, fusion level and follow-up time, were meticulously documented. Radiographic parameters were measured on standing whole-spine posteroanterior and lateral radiographs preoperatively, immediately after surgery, and last follow-time, by using Surgimap (Nemaris, Inc, New York, NY), including coronal balance distance(CBD, the distance between C7 plumb line and central sacral vertical line), thoracic cobb, thoracolumbar/lumbar cobb, apical vertebral translation of thoracic curve(T-AVT, the distance between the geometrical center of the apical vertebra of the thoracic curve and the C7PL), apical vertebral translation of thoracolumbar/lumbar curve(TL/L-AVT, the distance between the geometrical center of the apical vertebra of the thoracolumbar/lumbar curve and the CSVL), thoracic flexibility. Document the patient's coronal balance pattern at the latest follow-up, the progression of thoracic curvature (difference in Cobb angle of thoracic curvature between the last follow-up and immediately post-operation exceeding 5°), distal decompensation, implant migration, and implant fracture. Quality of life evaluation was performed utilizing the SRS-22 scale, completed by patients at 2-year follow-up. The SRS-22 scale evaluates five domains: appearance, psychology, activity, pain, and satisfaction. It comprises 22 questions, each rated from 1 to 5, where 1 represents the worst outcome and 5 the best. Coronal patterns were classified into Type A, CBD 20mm and C7PL shifted to concave side of main curve; Type C, CBD> 20mm and C7PL shifted to convex side of main curve according to coronal balance distance and coronal C7 plumbline relative to main curve position. Coronal pattern of Type B was rarely found in Lenke 5C AIS [12] , and none of patients was classified into coronal Type B preoperatively according to the definition of coronal patterns in this study. Based on the preoperative coronal pattern, patients were categorized into Group Type A and Group Type C. Patients in Group Type A underwent selective fusion. Group Type C was then subdivided into the Group Type C1(underwent selective fusion) and the Group Type C2(underwent non-selective fusion), depending on the fusion strategy of the thoracic curvature. Statistical analysis The data were analyzed using IBM SPSS Statistics version 27.0 (IBM Co, Armonk, NY, USA). Paired t-tests, student's t test, chi-square tests, and Fisher's exact tests were employed to compare between groups, adhering to statistical principles. A significance level of P < 0.05 was set for all tests. Results The study included a cohort of 119 patients diagnosed with Lenke 5C Adolescent Idiopathic Scoliosis (AIS), consisting of 19 male and 100 female individuals. There was no significant difference in thoracic curve flexibility between Group Type A and Group Type C. The baseline data was shown in Table 1 . Comparison of clinical outcomes after selective fusion in patients with different pre-operative coronal balance patterns There were no statistically significant differences in the thoracolumbar/lumbar cobb, and thoracic cobb between the Type C1 group and the Type A group (P > 0.05) at baseline (Table 2 ). In the Type A group, the thoracic curve improved from 31.70 ± 4.69° preoperatively to 18.88 ± 5.52° postoperatively, but worsened by the final follow-up (21.60 ± 6.16°, P < 0.001). The thoracolumbar/lumbar curve was corrected from 49.28 ± 8.03° to 15.67 ± 7.09° postoperatively, maintaining satisfactory correction at follow-up (16.05 ± 5.98°, P = 0.511). In the Type C1 group, the thoracic curve was reduced from 31.85 ± 3.49° to 16.63 ± 4.12° postoperatively, with deterioration at follow-up (21.63 ± 5.81°, P < 0.001). The thoracolumbar/lumbar curve improved from 49.34 ± 6.83° to 15.51 ± 5.40°, maintaining correction at follow-up (16.22 ± 6.57°, P = 0.460). At final follow-up, thoracic curve progression occurred in 9 of 43 cases (20.9%) in the Type A group, with 2 cases exceeding 10° progression. In the Type C1 group, 20 of 41 cases (48.8%) showed progression, with 9 cases exceeding 10°. Comparison of postoperative complications between coronal Type A and C1 groups were shown in Table 3 . In the Type A group, the majority of patients (36/43, 83.7%) maintained coronal balance after surgery, with no instances of coronal imbalance during the follow-up period. However, 7 cases (7/43, 16.3%) exhibited immediate postoperative coronal imbalance, all of which were classified as Type C. By the final follow-up, only 1 case in this group still had coronal imbalance (Type C). In the Type C1 group, 25 cases (25/41, 61.0%) showed immediate postoperative improvement in coronal balance (CBD < 20 mm), while 3 cases developed coronal imbalance during the follow-up (1 case of Type B and 2 cases of Type C). Sixteen cases (16/41, 19.0%) still had immediate postoperative coronal imbalance, and 4 cases did not demonstrate improvement in coronal balance during the follow-up (Type C). At the final follow-up, 5 cases in each group developed distal decompensation, but none of them required revision surgery. Comparison of clinical outcomes of different fusion strategies in Lenke 5C patients with preoperative coronal pattern of Type C Compared with Type C1 group, the Type C2 group had larger thoracic curve (34.86 ± 4.64 vs. 31.85 ± 3.49, P = 0.002) and T-AVT (15.65 ± 5.89 vs. 21.19 ± 6.81, P 0.05) preoperatively. In the NSF group, thoracolumbar/lumbar curves were corrected from 48.94 ± 9.05° preoperatively to 10.83 ± 4.10° postoperatively, while thoracic curves improved from 34.86 ± 4.64° to 11.14 ± 4.30°. This correction was largely maintained at follow-up (10.83 ± 4.10° vs. 11.89 ± 5.41°, P = 0.103; 11.14 ± 4.30° vs. 11.40 ± 3.98°, P = 0.401). In the Type C2 group, 22 cases demonstrated immediate postoperative restoration of coronal balance, which was well preserved at the final follow-up. Conversely, 13 patients exhibited persistent coronal imbalance (Type C) immediately after surgery. By the last follow-up, only 1 patient continued to have unrestored coronal balance (Type C). During the follow-up period in the NSF group, 4 patients experienced distal decompensation, yet none required revision surgery. (Table 5 ) At the 2-year follow-up, the Type C2 group exhibited higher pain and appearance scores compared to the Type C1 group (4.88 ± 0.10 vs. 4.55 ± 0.50, P = 0.020; 4.33 ± 0.51 vs. 3.87 ± 0.55, P = 0.003). No significant differences were observed in activity, psychology, and satisfaction scores between the groups (Table 6 ). Discussion This study investigated the postoperative clinical outcomes of different surgical fusion strategies for Lenke 5C adolescent idiopathic scoliosis patients with preoperative coronal imbalance and poor compensatory ability of the thoracic curve. We found that among Lenke 5C patients with preoperative coronal pattern of Type C who underwent selective fusion, 48.7% experienced thoracic curve progression, and 17.1% remained coronal imbalance at the last follow-up. In contrast, patients who underwent non-selective fusion exhibited well-corrected thoracic and thoracolumbar/lumbar curves. Only 5.7% of these patients failed to restore coronal balance at the last follow-up. Non-selective fusion surgery does not significantly affect functional activities, and patients also have better image evaluation after surgery. These findings suggest that selective fusion surgery should be cautiously applied to Lenke 5C patients with preoperative coronal imbalance and poor thoracic compensatory ability. Lenke 5C AIS patients can achieve satisfactory coronal and sagittal improvements through selective thoracolumbar/lumbar fusion, with subsequent spontaneous correction of the unfused thoracic curve. [14,15] Several studies had reported that the unfused thoracic curve can be well maintained after surgery, and the long-term follow-up data indicated that the correction rate of unfused thoracic curve indistinctively decreased over time. [16,17] However, the postoperative spontaneous correction rate in these patients is notably lower than anticipated (flexibility of thoracic curve measured on preoperative supine bending films). [18,19] Few articles had reported related factors influencing the progression of unfused thoracic curve. Our research showed that compared with Type A, patients with preoperative coronal Type C and poor thoracic compensatory ability had significantly higher proportion of thoracic curve progression following selective thoracolumbar/lumbar fusion surgery (20.9% vs. 48.7%, P = 0.005). The result suggested that the preoperative coronal pattern may influence the progression of the unfused thoracic curve during the follow-up period. The spontaneous correction of unfused thoracic curvature involves two processes: immediate spontaneous correction after surgery and chronic spontaneous correction during follow-up when the fused thoracolumbar/lumbar curve was relatively stable. [20] We considered that during follow-up, the restoration of coronal balance primarily relied on the progression of the thoracic curve, given the fusion of the thoracolumbar/lumbar curves. And the rate of thoracic progression observed in our study was relatively higher compared to that reported in previous study, [11] potentially due to the utilization of a more stringent threshold for defining thoracic progression. Li et al [21] found that preoperative thoracic curvature and thoracic curvature on lateral bending were strongly correlated with the final thoracic curvature. This result differed from our research findings. In our study, there was no significant difference in the preoperative and final thoracic cobb between Type A group and Type C1 group, indicating that the progression of the thoracic curve during the follow-up might not be caused by a larger preoperative thoracic curve. Zhang et al [20] observed higher flexibility was an independent risk factor for correction loss of the unfused thoracic curve during the follow-up, and the author explained that higher flexibility and spontaneous correction rate may cause a larger margin of magnitude change. Since our study included patients with poor thoracic compensatory ability and there was similar thoracic curve flexibility between the Type A and Type C groups, the impact of higher flexibility on postoperative thoracic curve progression needed further research. The appropriate time to apply non-selective fusion surgery for AIS patients with Lenke 5C remains uncertain. Kwan et al [4] studied the flexibility of the thoracic curves in Lenke 5 and Lenke 6, categorizing Lenke 5C into Lenke 5- and Lenke 5+. The author found comparable compensatory abilities between the thoracic curves of Lenke 5 + and Lenke 6, and suggested that non-selective fusion might be more appropriate for Lenke 5+. Currently, few articles have compared the clinical efficacy of different fusion strategies in Lenke 5C patients with poor compensatory ability of the thoracic curve. Chang et al [5] evaluated the postoperative outcomes of selective fusion surgery in Lenke 5 and Lenke 6 patients, and their findings suggested that the correction in Lenke 6 cases was less effective than that in Lenke 5 cases. This indicated that Lenke 5C AIS patients with poor compensatory ability of the thoracic curve may need to consider undergoing non-selective fusion surgery. Coronal imbalance can significantly impact postoperative appearance and patient satisfaction, which is also an important consideration for surgeons when planning surgical strategies. Although coronal imbalance is typically assessed by CBD exceeding a specific threshold, numerical evaluation alone does not fully capture coronal morphology. To address this, Bao et al. [22] introduced a classification based on the relative position of trunk shifted to the main curve, categorizing coronal morphology into Types A, B, and C. Based on this coronal classification, Fang et al [12] found that preoperative coronal balance patterns influence postoperative balance restoration, with approximately 29% of patients with preoperative Type C continuing to exhibit imbalance during follow-up. Previous research also indicated that reduced thoracic flexibility and immediately postoperative coronal imbalance are risk factors for persistent postoperative coronal imbalance [9] . The above studies only considered the influencing factors of postoperative coronal imbalance from a single aspect, while our study comprehensively evaluated the clinical outcomes of different fusion strategies based on the patients' coronal pattern and poor thoracic compensatory ability. Our results showed that 17.1% of patients with poor thoracic compensatory ability and preoperative coronal Type C exhibited persistent coronal imbalance, compared to 2.3% with preoperative coronal Type A. Nearly 40% of patients with preoperative coronal Type C still had coronal imbalance after non-selective fusion surgery, whereas most patients were able to restore coronal balance at the last follow-up. All patients did not report significant pain, nor was there evidence of internal fixation loosening or breakage, negating the need for revision surgery. These findings indicated that patients with Type C coronal imbalance and poor thoracic compensatory ability may risk thoracic curve progression and suboptimal balance restoration after selective fusion. Therefore, surgical planning for such patients should consider selective fusion cautiously. In recent years, the postoperative quality of life for patients with adolescent idiopathic scoliosis has gained significant attention. Various assessment scales are used, with the Scoliosis Research Society's SRS-22 questionnaire being prominent. [23,24] This study focused on comparing postoperative quality of life in patients with preoperative coronal Type C AIS who underwent different fusion strategies. Findings indicated that patients who received non-selective fusion reported superior pain and self-image scores, while no significant differences were observed in psychological well-being, function, or satisfaction. These outcomes likely result from improved shoulder balance following thoracic curve fixation and fusion. Limitation This study had several limitations: (1) As a retrospective study, it may suffer from selection bias due to the loss of some patients’ follow-up; (2) A large thoracic curve was deemed a factor for non-selective fusion, resulting in a relatively larger preoperative thoracic curve in the Type C2 group compared to the Type C1 group; (3) coronal Type B is very rare in Lenke 5C AIS. [12] In this study, none was classified into preoperative Type B group, which does not allow us to explore the discrepancies among Type A, B, and C groups. Conclusion The study indicates that Lenke 5C AIS patients with preoperative coronal Type C and poor thoracic curve compensation are susceptible to thoracic curve progression and suboptimal coronal plane restoration following selective fusion. In such clinical scenarios, non-selective fusion achieves effective correction of the thoracic curve, improves patients’ self-perception of body image, and avoids increasing the risk of distal decompensation—without imposing significant restrictions on postoperative mobility. Surgeons should take caution when considering selective fusion in surgical planning for these patients. Declarations Ethics approval and consent to participate ： This study was approved by the Institutional Review Board (IRB) of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (IRB No. 2021-398-01). Freely given, informed consent was obtained from these patients in this study for all procedures undertaken and all data obtained. This study adhered to the Declaration of Helsinki. Consent for publication ： Not applicable. Availability of data and materials ： The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests ： The authors declare that they have no competing interests. Funding ： This work was supported by the Jiangsu Provincial Medical Innovation Center of Orthopedic Surgery (CXZX202214) and National Natural Science Foundation of China (82502981). Author’s contributions: Chunxiao Chen: Conception and design, acquisition and data, writing, critical revision. Qiang Liu: Conception and design, acquisition and data, analysis and interpretation of data, critical revision. Jie Li: Conception and design, critical revision, supervision. Xiaodong Qin: acquisition and data, critical revision. Benlong Shi: acquisition and data, critical revision. Saihu Mao: acquisition and data, critical revision. Yong Qiu: Conception and design, critical revision. Zezhang Zhu: Conception and design, critical revision. Zhen Liu: Conception and design, critical revision, obtaining funding, supervision. All authors reviewed the manuscript. Acknowledgements: Not applicable. References LARK RK, YASZAY B, BASTROM TP, et al. Adding Thoracic Fusion Levels in Lenke 5 Curves[J]. Spine, 2013, 38(2): 195-200. YOSHIHARA H. Surgical Treatment of Lenke Type 5 Adolescent Idiopathic Scoliosis[J]. Spine, 2019, 44(13): E788-E799. CAMPBELL RE, RUDIC T, HAFEY A, et al. Curve progression following selective and nonselective spinal fusion for adolescent idiopathic scoliosis: are selective fusions stable? [J]. Spine Deformity, 2024, 13(1): 177-187. KWAN MK, CHIU CK, CHAN TS, et al. Flexibility assessment of the unfused thoracic segments above the “potential upper instrumented vertebrae” using the supine side bending radiographs in Lenke 5 and 6 curves for adolescent idiopathic scoliosis patients[J]. The Spine Journal, 2018, 18(1): 53-62. CHANG SY, SON J, ZHENG GB, et al. Clinical outcomes of selective fusion for the thoracolumbar-lumbar curve in patients with Lenke type 6C adolescent idiopathic scoliosis: a preliminary study[J]. J Pediatr Orthop B, 2021, 30(3): 211-217. MATSUMURA A, IWAMAE M, NAMIKAWA T, et al. Spontaneous Improvement of Postoperative Coronal Imbalance Following Selective Thoracolumbar-Lumbar Fusion in Lenke 5C Adolescent Idiopathic Scoliosis[J]. World Neurosurgery, 2021, 151: e241-e249. SHETTY AP, SURESH S, AIYER SN, et al. Radiological factors affecting post-operative global coronal balance in Lenke 5 C scoliosis[J]. Journal of Spine Surgery, 2017, 3(4): 541-547. YANG C, ZHAO Y, ZHAI X, et al. Coronal balance in idiopathic scoliosis: a radiological study after posterior fusion of thoracolumbar/lumbar curves (Lenke 5 or 6) [J]. European Spine Journal, 2016, 26(6): 1775-1781. QIAO H, YAN K, LIAO B. Risk of coronal imbalance after posterior surgery for adolescent idiopathic scoliosis of type Lenke5C[J]. Current Medical Research and Opinion, 2024, 40(10): 1785-1791. YANG X, HU B, SONG Y, et al. Coronal and sagittal balance in Lenke 5 AIS patients following posterior fusion: important role of the lowest instrument vertebrae selection[J]. BMC Musculoskeletal Disorders, 2018, 19(1). ZHANG T, SHU S, JING W, et al. Optimizing the fusion level for lenke 5C adolescent idiopathic scoliosis: is the S-line a validated and reproducible tool to predict coronal decompensation? [J]. European Spine Journal, 2021, 30(7): 1935-1942. FANG Y, LI J, HU Z, et al. Postoperative Coronal Imbalance in Lenke 5C Adolescent Idiopathic Scoliosis: Evolution, Risk Factors, and Clinical Implications[J]. Neurospine, 2024, 21(3): 903-912. KARADEMIR G, SARIYILMAZ K, DEMIREL M, et al. Does Thoracic Kyphosis Have any Importance in Selective Versus Nonselective Fusion Preference in Patients with Lenke Type 5C Adolescent Idiopathic Scoliosis? [J]. Turkish neurosurgery, 2023, 33: 118-125. ZHANG Y, LIN G, ZHANG J, et al. Radiographic evaluation of posterior selective thoracolumbar or lumbar fusion for moderate Lenke 5C curves[J]. Archives of Orthopaedic and Trauma Surgery, 2016, 137(1): 1-8. TAUCHI R, KAWAKAMI N, OHARA T, et al. Sagittal Alignment Profile Following Selective Thoracolumbar/Lumbar Fusion in Patients with Lenke Type 5C Adolescent Idiopathic Scoliosis[J]. Spine, 2019, 44(17): 1193-1200. LOUER C, YASZAY B, CROSS M, et al. Ten-Year Outcomes of Selective Fusions for Adolescent Idiopathic Scoliosis[J]. Journal of Bone and Joint Surgery, 2019, 101(9): 761-770. CHEN K, CHEN Y, SHAO J, et al. Long-Term Follow-up of Posterior Selective Thoracolumbar/Lumbar Fusion in Patients with Lenke 5C Adolescent Idiopathic Scoliosis: An Analysis of 10-Year Outcomes[J]. Global Spine Journal, 2020, 12(5): 840-850. DONG Y, WENG X, ZHAO H, et al. Lenke 5C Curves in Adolescent Idiopathic Scoliosis[J]. Neurosurgery, 2016, 78(3): 324-331. SCHULTE TL, LILJENQVIST U, HIERHOLZER E, et al. Spontaneous Correction and Derotation of Secondary Curves After Selective Anterior Fusion of Idiopathic Scoliosis[J]. Spine, 2006, 31(3): 315-321. ZHANG Y, LIN G, WANG S, et al. Higher Flexibility and Better Immediate Spontaneous Correction May Not Gain Better Results for Nonstructural Thoracic Curve in Lenke 5C AIS Patients[J]. Spine, 2016, 41(22): 1731-1739. LI M, FANG X, SUN Y, et al. Thoracic curve correction after posterior fusion and instrumentation of structural lumbar curves in patients with adolescent idiopathic scoliosis[J]. Archives of Orthopaedic and Trauma Surgery, 2011, 131(10): 1375-1381. BAO H, ZHU F, LIU Z, et al. Coronal Curvature and Spinal Imbalance in Degenerative Lumbar Scoliosis[J]. Spine, 2014, 39(24): E1441-E1447. KARAKAYA I, SISMANLAR SG, ATMACA H, et al. Outcome in early adolescent idiopathic scoliosis after deformity correction[J]. Journal of Pediatric Orthopaedics B, 2012, 21(4): 317-321. FRANTZÉN A, SUOMINEN E N, SAARINEN A J, et al. Association Between Lenke Classification, The Extent of Lumbar Spinal Fusion, and Health-Related Quality of Life After Instrumented Spinal Fusion for Adolescent Idiopathic Scoliosis[J]. Spine, 2023, 48(17): 1216-1223. Tables Table 1 . Comparison of baseline data between Group Type A and Group Type C A group （n=43） C group （n=76） P value Age(yrs) 15.05±2.14 14.88±1.42 0.670 Gender (male: female) 8:35 11:65 0.555 Risser sign 3.30±1.17 3.44±0.84 0.541 T curve flexibility (%) 43.10±10.02 44.62±9.94 0.487 Follow-up time 32.30±15.25 34.05±17.33 0.582 Table 1: T curve flexibility: thoracic curve flexibility. Table 2 . Comparison of Radiographic parameters between Coronal Type A and Type C1 groups in patients with selective fusion. Type A group （n=43） Type C1 group （n=41） P value CBD (mm) Pre-op 12.39±5.94 32.07±7.83 <0.001 Po-op 14.80±9.46 18.54±11.73 0.111 Follow-up 10.28±7.18 14.06±7.42 0.020 T curve (°) Pre-op 31.70±4.69 31.85±3.49 0.864 Po-op 18.88±5.52 16.63±4.12 0.038 Follow-up 21.60±6.16 21.63±5.81 0.982 TL/L curve (°) Pre-op 49.28±8.03 49.34±6.83 0.970 Po-op 15.67±7.09 15.51±5.40 0.906 Follow-up 16.05±5.98 16.22±6.57 0.900 T-AVT (mm) Pre-op 10.49±6.60 15.65±5.89 <0.001 Po-op 13.08±7.66 13.46±6.52 0.815 Follow-up 13.12±8.22 12.17±5.5 0.686 TL/L-AVT (mm) Pre-op 47.01±8.82 51.86±8.92 0.020 Po-op 18.89±5.96 19.03±6.18 0.930 Follow-up 17.71±6.68 20.38±6.83 0.158 Fusion level 5.53±0.84 5.67±0.84 0.530 Table 2: Pre-op: pre-operation; Po-op: post-operation; CBD: coronal balance distance; T curve: thoracic curve; TL/L curve: thoracolumbar/lumbar curve; T-AVT: thoracic apical vertebra translation; TL/L-AVT: thoracolumbar/lumbar apical vertebra translation. Table 3 . Comparison of postoperative complications between Coronal Type A and C1groups in patients with selective fusion Type A group （n=43） Type C1 group （n=41） P value Proximal decompensation 9(20.9%) 20(48.7%) 0.005 Distal decompensation 5(11.6%) 5(12.1%) 1.000 Coronal imbalance Po-op 7(16.3%) 16(39%) 0.019 Follow-up 1(2.3%) 7(17.1%) 0.028 Table 3: Pre-op: pre-operation; Po-op: post-operation. Table 4 . Comparison of Radiographic parameters between Type C1 group and Type C2 group patients with preoperative Type C and poor thoracic compensatory ability. Type C1 group （n=41） Type C2 group （n=35） P value CBD (mm) Pre-op 32.07±7.83 31.20±7.82 0.507 Po-op 18.54±11.73 21.10±12.40 0.359 Follow-up 14.06±7.42 14.72±6.90 0.910 T curve (°) Pre-op 31.85±3.49 34.91±4.61 0.002 Po-op 16.63±4.12 11.46±4.53 <0.001 Follow-up 21.63±5.81 11.34±4.12 <0.001 TL/L curve (°) Pre-op 49.34±6.83 50.01±9.61 0.828 Po-op 15.51±5.40 10.42±4.34 <0.001 Follow-up 16.22±6.57 11.52±6.10 0.003 T-AVT (mm) Pre-op 15.65±5.89 21.19±6.81 <0.001 Po-op 13.46±6.52 9.16±6.18 0.005 Follow-up 12.17±5.5 7.14±5.24 0.007 TL/L-AVT (mm) Pre-op 51.86±8.92 49.55±8.01 0.253 Po-op 19.03±6.18 22.73±6.75 0.037 Follow-up 20.38±6.83 20.62±6.52 0.893 Table 4: Pre-op: pre-operation; Po-op: post-operation; CBD: coronal balance distance; T flexibility: flexibility of thoracic curve; T curve: thoracic curve; TL/L curve: thoracolumbar/lumbar curve; T-AVT: thoracic apical vertebra translation; TL/L-AVT: thoracolumbar/lumbar apical vertebra translation. Table 5 . Comparison of postoperative complications between Type C1 group and Type C2 group patients with preoperative Type C and poor thoracic compensatory ability. Type C1 group （n=41） Type C2 group （n=35） P value Proximal decompensation 20(48.7%) 0(0.0%) <0.001 Distal decompensation 5(12.1%) 4(11.4%) 1.000 Coronal imbalance Po-op 16(39.0%) 13(37.1%) 0.866 Follow-up 7(17.1%) 1(2.8%) 0.063 Table 5: Pre-op: pre-operation; Po-op: post-operation. Table 6 . Comparison of SRS-22 scores between Type C1 group and Type C2 group at 2-year follow-up. Type C1 group （n=41） Type C2 group （n=35） P value Pain 4.55±0.50 4.88±0.10 0.020 Function 3.91±0.57 4.13±0.45 0.251 Image 3.87±0.55 4.33±0.51 0.003 Mental 4.20±0.57 4.33±0.62 0.519 Satisfaction 4.24±0.74 4.38±0.53 0.575 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 27 Apr, 2026 Read the published version in Journal of Orthopaedic Surgery and Research → Version 1 posted Editorial decision: Revision requested 10 Feb, 2026 Reviews received at journal 09 Feb, 2026 Reviews received at journal 06 Feb, 2026 Reviews received at journal 05 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers agreed at journal 03 Feb, 2026 Reviewers agreed at journal 03 Feb, 2026 Reviewers agreed at journal 03 Feb, 2026 Reviewers invited by journal 03 Feb, 2026 Submission checks completed at journal 02 Feb, 2026 Editor assigned by journal 02 Feb, 2026 First submitted to journal 30 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8548158","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":585960539,"identity":"77346498-5a04-4f09-8e03-851b046a297f","order_by":0,"name":"Chunxiao Chen","email":"","orcid":"","institution":"Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chunxiao","middleName":"","lastName":"Chen","suffix":""},{"id":585960541,"identity":"d8bac5db-153d-46d9-b614-04b2236105ca","order_by":1,"name":"Qiang Liu","email":"","orcid":"","institution":"Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Qiang","middleName":"","lastName":"Liu","suffix":""},{"id":585960543,"identity":"16c82caa-a997-4429-93c4-9e8e988e264a","order_by":2,"name":"Jie Li","email":"","orcid":"","institution":"Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University","correspondingAuthor":false,"prefix":"","firstName":"Jie","middleName":"","lastName":"Li","suffix":""},{"id":585960546,"identity":"b9b096d4-1fa7-40a0-8814-4642a1d6ea7b","order_by":3,"name":"Xiaodong Qin","email":"","orcid":"","institution":"Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University","correspondingAuthor":false,"prefix":"","firstName":"Xiaodong","middleName":"","lastName":"Qin","suffix":""},{"id":585960547,"identity":"b8aaf166-1a36-4175-97ed-198405d4834e","order_by":4,"name":"Benlong Shi","email":"","orcid":"","institution":"Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University","correspondingAuthor":false,"prefix":"","firstName":"Benlong","middleName":"","lastName":"Shi","suffix":""},{"id":585960549,"identity":"31a58f55-5b75-491c-8e4c-bb62e26b62da","order_by":5,"name":"Saihu Mao","email":"","orcid":"","institution":"Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University","correspondingAuthor":false,"prefix":"","firstName":"Saihu","middleName":"","lastName":"Mao","suffix":""},{"id":585960553,"identity":"8d9e244c-f859-4745-a279-5514df2e7628","order_by":6,"name":"Yong Qiu","email":"","orcid":"","institution":"Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Qiu","suffix":""},{"id":585960554,"identity":"e025240d-131d-4bc3-81a6-d9ba46c3764c","order_by":7,"name":"Zezhang Zhu","email":"","orcid":"","institution":"Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University","correspondingAuthor":false,"prefix":"","firstName":"Zezhang","middleName":"","lastName":"Zhu","suffix":""},{"id":585960555,"identity":"7798396a-caea-42e8-b6f9-22bd32057aaf","order_by":8,"name":"Zhen Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYDCCA8wNB4AkAwN7Y+PDD8RpYYRq4TncbCxBrBYGsBaJ9DYBHmJ08N0+2HiY588dOXPJh20MEgx2croNBLRInktsOMzD88zYcnZi24MChmRjswMEtBicYQRqkTicuOF2YruBBMOBxG3EaTE4XL/h5sE2CR7itSQcTjC4wUikFkmgloNzDhw23HAmERjIBkT4he8M8+EPb/4cljc4fvzhww8VdnIEtaC7kzTlo2AUjIJRMApwAADXbUwX7Va3FgAAAABJRU5ErkJggg==","orcid":"","institution":"Division of Spine Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University","correspondingAuthor":true,"prefix":"","firstName":"Zhen","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2026-01-08 07:24:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8548158/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8548158/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13018-026-06874-5","type":"published","date":"2026-04-27T15:58:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":108437707,"identity":"9c11efa6-a289-4d77-a1ab-29ad8fc29ecb","added_by":"auto","created_at":"2026-05-04 16:02:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":349808,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8548158/v1/96b91c08-cafd-467c-9498-8cceeed6d62c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Optimizing surgical strategy in Lenke 5C AIS patients with poor thoracic compensatory ability: is there a role of coronal imbalance?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn the surgical management of Lenke 5C adolescent idiopathic scoliosis (AIS), selective fusion is favored to maximize spinal mobility, and the unfused curve could be spontaneously corrected postoperatively since the good flexibility of thoracic curve.\u003csup\u003e[1\u0026ndash;3]\u003c/sup\u003e While Kwan\u003csup\u003e[4]\u003c/sup\u003e found that Lenke 5\u0026thinsp;+\u0026thinsp;patients (thoracic Cobb angle\u0026thinsp;\u0026gt;\u0026thinsp;15\u0026deg; on supine bending films) exhibit similar thoracic compensatory ability to Lenke 6, suggesting non-selective fusion for Lenke 5\u0026thinsp;+\u0026thinsp;AIS. Although study \u003csup\u003e[5]\u003c/sup\u003e indicated that patients with limited thoracic curve compensation can achieve spontaneous correction after selective fusion and maintain good long-term quality of life, the correction rate of thoracic curve is unsatisfactory. Furthermore, the evolution of the non-fused thoracic curve in patients over extended follow-up periods is not well understood. Consequently, there is a need for further research to determine the optimal fusion strategy for Lenke 5C AIS patients with poor thoracic compensatory ability.\u003c/p\u003e \u003cp\u003eCoronal imbalance remains a frequent postoperative complication in Lenke 5C AIS patients, impacting their appearance and satisfaction after surgery, and severe imbalance may necessitate revision surgery. Literatures indicated that 6.9% to 17.4% of Lenke 5C patients who underwent selective thoracolumbar/lumbar curve fusion experienced coronal imbalance during follow-up.\u003csup\u003e[6,7]\u003c/sup\u003e Although several risk factors for persistent coronal imbalance (PCI) such as a larger L5 tilt, LIV tilt\u0026thinsp;\u0026gt;\u0026thinsp;25\u0026deg;, selection of L5 as LIV, poor thoracic curve flexibility, larger preoperative AVT\u0026ndash;TL/L, and immediate postoperative coronal imbalance had been reported\u003csup\u003e[8\u0026ndash;11]\u003c/sup\u003e, clinicians are constantly exploring how to improve the postoperative coronal balance. The recent research \u003csup\u003e[12]\u003c/sup\u003e found that Lenke 5C patients with preoperative coronal pattern of Type C (coronal balance distance [CBD]\u0026thinsp;\u0026gt;\u0026thinsp;20 mm and C7 plumbline[C7PL] shifted to convex side of main curve) had suboptimal coronal restoration following selective fusion surgery, resulting in 29% remaining coronal imbalance at the last follow-up. This highlights the importance of considering the preoperative coronal patterns' impact on postoperative coronal balance restoration when planning surgical interventions. While non-selective fusion more effectively improves coronal deformity, correcting thoracic curve and controlling its progression, it may decrease the thoracic kyphosis and clinical flexibility. Clinicians need to plan surgical strategies based on patients' conditions to achieve maximum benefits. Such as previous study had suggested that Lenke 5C AIS patients with thoracic kyphosis are more suitable for non-selective fusion surgery.\u003csup\u003e[13]\u003c/sup\u003e While few studies analyzed the impact of poor thoracic coronal compensation ability and preoperative coronal pattern on clinical efficacy following different fusion strategies.\u003c/p\u003e \u003cp\u003eThis study aims to: (1) evaluate the clinical outcomes of Lenke 5C patients with different preoperative coronal balance patterns and poor thoracic coronal compensation ability after selective thoracolumbar/lumbar fusion; (2) compare the clinical outcomes of Lenke 5C patients with preoperative coronal Type C and poor thoracic coronal compensation ability undergoing different fusion strategies. We hypothesized that Lenke 5C patients with preoperative coronal Type C and poor thoracic compensatory ability may benefit more from non-selective fusion compared with selective fusion.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSubjects\u003c/h2\u003e \u003cp\u003eThis is a retrospective cohort study that was performed for AIS underwent posterior spine fusion surgery from March 2012 to February 2023. The main inclusion criteria were about (1) clinical diagnosis as Lenke 5C AIS patients; (2) poor thoracic compensation ability, defined as thoracic cobb angle on supine bending film between 15 and 25\u0026deg; preoperatively \u003csup\u003e[4]\u003c/sup\u003e; (3) followed up at least 2 years; (4) complete preoperative, postoperative and follow-up clinical data. The exclusion criteria were as follows: (1) patients with previous surgery related to spine, pelvis and lower extremities; (2) spinal deformities with definite etiology, such as tumor, congenital scoliosis and neurogenic scoliosis.\u003c/p\u003e \u003cp\u003e This study was approved by the Institutional Review Board (IRB) of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (IRB No. 2021-398-01).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection and measurement\u003c/h3\u003e\n\u003cp\u003eThe demographic data, including age, gender, Risser sign, fusion level and follow-up time, were meticulously documented. Radiographic parameters were measured on standing whole-spine posteroanterior and lateral radiographs preoperatively, immediately after surgery, and last follow-time, by using Surgimap (Nemaris, Inc, New York, NY), including coronal balance distance(CBD, the distance between C7 plumb line and central sacral vertical line), thoracic cobb, thoracolumbar/lumbar cobb, apical vertebral translation of thoracic curve(T-AVT, the distance between the geometrical center of the apical vertebra of the thoracic curve and the C7PL), apical vertebral translation of thoracolumbar/lumbar curve(TL/L-AVT, the distance between the geometrical center of the apical vertebra of the thoracolumbar/lumbar curve and the CSVL), thoracic flexibility. Document the patient's coronal balance pattern at the latest follow-up, the progression of thoracic curvature (difference in Cobb angle of thoracic curvature between the last follow-up and immediately post-operation exceeding 5\u0026deg;), distal decompensation, implant migration, and implant fracture. Quality of life evaluation was performed utilizing the SRS-22 scale, completed by patients at 2-year follow-up. The SRS-22 scale evaluates five domains: appearance, psychology, activity, pain, and satisfaction. It comprises 22 questions, each rated from 1 to 5, where 1 represents the worst outcome and 5 the best.\u003c/p\u003e \u003cp\u003eCoronal patterns were classified into Type A, CBD\u0026lt;20mm; Type B, CBD\u0026gt; 20mm and C7PL shifted to concave side of main curve; Type C, CBD\u0026gt; 20mm and C7PL shifted to convex side of main curve according to coronal balance distance and coronal C7 plumbline relative to main curve position.\u003c/p\u003e \u003cp\u003eCoronal pattern of Type B was rarely found in Lenke 5C AIS \u003csup\u003e[12]\u003c/sup\u003e, and none of patients was classified into coronal Type B preoperatively according to the definition of coronal patterns in this study. Based on the preoperative coronal pattern, patients were categorized into Group Type A and Group Type C. Patients in Group Type A underwent selective fusion. Group Type C was then subdivided into the Group Type C1(underwent selective fusion) and the Group Type C2(underwent non-selective fusion), depending on the fusion strategy of the thoracic curvature.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe data were analyzed using IBM SPSS Statistics version 27.0 (IBM Co, Armonk, NY, USA). Paired t-tests, student's t test, chi-square tests, and Fisher's exact tests were employed to compare between groups, adhering to statistical principles. A significance level of P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was set for all tests.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included a cohort of 119 patients diagnosed with Lenke 5C Adolescent Idiopathic Scoliosis (AIS), consisting of 19 male and 100 female individuals. There was no significant difference in thoracic curve flexibility between Group Type A and Group Type C. The baseline data was shown in Table \u003cspan\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003ch3\u003eComparison of clinical outcomes after selective fusion in patients with different pre-operative coronal balance patterns\u003c/h3\u003e\n\u003cp\u003eThere were no statistically significant differences in the thoracolumbar/lumbar cobb, and thoracic cobb between the Type C1 group and the Type A group (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) at baseline (Table \u003cspan\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eIn the Type A group, the thoracic curve improved from 31.70\u0026thinsp;\u0026plusmn;\u0026thinsp;4.69\u0026deg; preoperatively to 18.88\u0026thinsp;\u0026plusmn;\u0026thinsp;5.52\u0026deg; postoperatively, but worsened by the final follow-up (21.60\u0026thinsp;\u0026plusmn;\u0026thinsp;6.16\u0026deg;, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The thoracolumbar/lumbar curve was corrected from 49.28\u0026thinsp;\u0026plusmn;\u0026thinsp;8.03\u0026deg; to 15.67\u0026thinsp;\u0026plusmn;\u0026thinsp;7.09\u0026deg; postoperatively, maintaining satisfactory correction at follow-up (16.05\u0026thinsp;\u0026plusmn;\u0026thinsp;5.98\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.511). In the Type C1 group, the thoracic curve was reduced from 31.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.49\u0026deg; to 16.63\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12\u0026deg; postoperatively, with deterioration at follow-up (21.63\u0026thinsp;\u0026plusmn;\u0026thinsp;5.81\u0026deg;, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The thoracolumbar/lumbar curve improved from 49.34\u0026thinsp;\u0026plusmn;\u0026thinsp;6.83\u0026deg; to 15.51\u0026thinsp;\u0026plusmn;\u0026thinsp;5.40\u0026deg;, maintaining correction at follow-up (16.22\u0026thinsp;\u0026plusmn;\u0026thinsp;6.57\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.460). At final follow-up, thoracic curve progression occurred in 9 of 43 cases (20.9%) in the Type A group, with 2 cases exceeding 10\u0026deg; progression. In the Type C1 group, 20 of 41 cases (48.8%) showed progression, with 9 cases exceeding 10\u0026deg;.\u003c/p\u003e\n\u003cp\u003eComparison of postoperative complications between coronal Type A and C1 groups were shown in Table \u003cspan\u003e3\u003c/span\u003e. In the Type A group, the majority of patients (36/43, 83.7%) maintained coronal balance after surgery, with no instances of coronal imbalance during the follow-up period. However, 7 cases (7/43, 16.3%) exhibited immediate postoperative coronal imbalance, all of which were classified as Type C. By the final follow-up, only 1 case in this group still had coronal imbalance (Type C). In the Type C1 group, 25 cases (25/41, 61.0%) showed immediate postoperative improvement in coronal balance (CBD\u0026thinsp;\u0026lt;\u0026thinsp;20 mm), while 3 cases developed coronal imbalance during the follow-up (1 case of Type B and 2 cases of Type C). Sixteen cases (16/41, 19.0%) still had immediate postoperative coronal imbalance, and 4 cases did not demonstrate improvement in coronal balance during the follow-up (Type C). At the final follow-up, 5 cases in each group developed distal decompensation, but none of them required revision surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparison of clinical outcomes of different fusion strategies in Lenke 5C patients with preoperative coronal pattern of Type C\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompared with Type C1 group, the Type C2 group had larger thoracic curve (34.86\u0026thinsp;\u0026plusmn;\u0026thinsp;4.64 vs. 31.85\u0026thinsp;\u0026plusmn;\u0026thinsp;3.49, P\u0026thinsp;=\u0026thinsp;0.002) and T-AVT (15.65\u0026thinsp;\u0026plusmn;\u0026thinsp;5.89 vs. 21.19\u0026thinsp;\u0026plusmn;\u0026thinsp;6.81, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while there were no significant differences in age, Risser sign, thoracolumbar/lumbar curve, CBD, and TL/L-AVT(P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) preoperatively. In the NSF group, thoracolumbar/lumbar curves were corrected from 48.94\u0026thinsp;\u0026plusmn;\u0026thinsp;9.05\u0026deg; preoperatively to 10.83\u0026thinsp;\u0026plusmn;\u0026thinsp;4.10\u0026deg; postoperatively, while thoracic curves improved from 34.86\u0026thinsp;\u0026plusmn;\u0026thinsp;4.64\u0026deg; to 11.14\u0026thinsp;\u0026plusmn;\u0026thinsp;4.30\u0026deg;. This correction was largely maintained at follow-up (10.83\u0026thinsp;\u0026plusmn;\u0026thinsp;4.10\u0026deg; vs. 11.89\u0026thinsp;\u0026plusmn;\u0026thinsp;5.41\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.103; 11.14\u0026thinsp;\u0026plusmn;\u0026thinsp;4.30\u0026deg; vs. 11.40\u0026thinsp;\u0026plusmn;\u0026thinsp;3.98\u0026deg;, P\u0026thinsp;=\u0026thinsp;0.401).\u003c/p\u003e\n\u003cp\u003eIn the Type C2 group, 22 cases demonstrated immediate postoperative restoration of coronal balance, which was well preserved at the final follow-up. Conversely, 13 patients exhibited persistent coronal imbalance (Type C) immediately after surgery. By the last follow-up, only 1 patient continued to have unrestored coronal balance (Type C). During the follow-up period in the NSF group, 4 patients experienced distal decompensation, yet none required revision surgery. (Table \u003cspan\u003e5\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eAt the 2-year follow-up, the Type C2 group exhibited higher pain and appearance scores compared to the Type C1 group (4.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10 vs. 4.55\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50, P\u0026thinsp;=\u0026thinsp;0.020; 4.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51 vs. 3.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.55, P\u0026thinsp;=\u0026thinsp;0.003). No significant differences were observed in activity, psychology, and satisfaction scores between the groups (Table \u003cspan\u003e6\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the postoperative clinical outcomes of different surgical fusion strategies for Lenke 5C adolescent idiopathic scoliosis patients with preoperative coronal imbalance and poor compensatory ability of the thoracic curve. We found that among Lenke 5C patients with preoperative coronal pattern of Type C who underwent selective fusion, 48.7% experienced thoracic curve progression, and 17.1% remained coronal imbalance at the last follow-up. In contrast, patients who underwent non-selective fusion exhibited well-corrected thoracic and thoracolumbar/lumbar curves. Only 5.7% of these patients failed to restore coronal balance at the last follow-up. Non-selective fusion surgery does not significantly affect functional activities, and patients also have better image evaluation after surgery. These findings suggest that selective fusion surgery should be cautiously applied to Lenke 5C patients with preoperative coronal imbalance and poor thoracic compensatory ability.\u003c/p\u003e \u003cp\u003eLenke 5C AIS patients can achieve satisfactory coronal and sagittal improvements through selective thoracolumbar/lumbar fusion, with subsequent spontaneous correction of the unfused thoracic curve. \u003csup\u003e[14,15]\u003c/sup\u003e Several studies had reported that the unfused thoracic curve can be well maintained after surgery, and the long-term follow-up data indicated that the correction rate of unfused thoracic curve indistinctively decreased over time.\u003csup\u003e[16,17]\u003c/sup\u003e However, the postoperative spontaneous correction rate in these patients is notably lower than anticipated (flexibility of thoracic curve measured on preoperative supine bending films).\u003csup\u003e[18,19]\u003c/sup\u003e Few articles had reported related factors influencing the progression of unfused thoracic curve. Our research showed that compared with Type A, patients with preoperative coronal Type C and poor thoracic compensatory ability had significantly higher proportion of thoracic curve progression following selective thoracolumbar/lumbar fusion surgery (20.9% vs. 48.7%, P\u0026thinsp;=\u0026thinsp;0.005). The result suggested that the preoperative coronal pattern may influence the progression of the unfused thoracic curve during the follow-up period.\u003c/p\u003e \u003cp\u003eThe spontaneous correction of unfused thoracic curvature involves two processes: immediate spontaneous correction after surgery and chronic spontaneous correction during follow-up when the fused thoracolumbar/lumbar curve was relatively stable.\u003csup\u003e[20]\u003c/sup\u003e We considered that during follow-up, the restoration of coronal balance primarily relied on the progression of the thoracic curve, given the fusion of the thoracolumbar/lumbar curves. And the rate of thoracic progression observed in our study was relatively higher compared to that reported in previous study,\u003csup\u003e[11]\u003c/sup\u003e potentially due to the utilization of a more stringent threshold for defining thoracic progression. Li et al \u003csup\u003e[21]\u003c/sup\u003e found that preoperative thoracic curvature and thoracic curvature on lateral bending were strongly correlated with the final thoracic curvature. This result differed from our research findings. In our study, there was no significant difference in the preoperative and final thoracic cobb between Type A group and Type C1 group, indicating that the progression of the thoracic curve during the follow-up might not be caused by a larger preoperative thoracic curve. Zhang et al \u003csup\u003e[20]\u003c/sup\u003e observed higher flexibility was an independent risk factor for correction loss of the unfused thoracic curve during the follow-up, and the author explained that higher flexibility and spontaneous correction rate may cause a larger margin of magnitude change. Since our study included patients with poor thoracic compensatory ability and there was similar thoracic curve flexibility between the Type A and Type C groups, the impact of higher flexibility on postoperative thoracic curve progression needed further research.\u003c/p\u003e \u003cp\u003eThe appropriate time to apply non-selective fusion surgery for AIS patients with Lenke 5C remains uncertain. Kwan et al \u003csup\u003e[4]\u003c/sup\u003e studied the flexibility of the thoracic curves in Lenke 5 and Lenke 6, categorizing Lenke 5C into Lenke 5- and Lenke 5+. The author found comparable compensatory abilities between the thoracic curves of Lenke 5\u0026thinsp;+\u0026thinsp;and Lenke 6, and suggested that non-selective fusion might be more appropriate for Lenke 5+. Currently, few articles have compared the clinical efficacy of different fusion strategies in Lenke 5C patients with poor compensatory ability of the thoracic curve. Chang et al \u003csup\u003e[5]\u003c/sup\u003e evaluated the postoperative outcomes of selective fusion surgery in Lenke 5 and Lenke 6 patients, and their findings suggested that the correction in Lenke 6 cases was less effective than that in Lenke 5 cases. This indicated that Lenke 5C AIS patients with poor compensatory ability of the thoracic curve may need to consider undergoing non-selective fusion surgery.\u003c/p\u003e \u003cp\u003eCoronal imbalance can significantly impact postoperative appearance and patient satisfaction, which is also an important consideration for surgeons when planning surgical strategies. Although coronal imbalance is typically assessed by CBD exceeding a specific threshold, numerical evaluation alone does not fully capture coronal morphology. To address this, Bao et al. \u003csup\u003e[22]\u003c/sup\u003e introduced a classification based on the relative position of trunk shifted to the main curve, categorizing coronal morphology into Types A, B, and C. Based on this coronal classification, Fang et al \u003csup\u003e[12]\u003c/sup\u003e found that preoperative coronal balance patterns influence postoperative balance restoration, with approximately 29% of patients with preoperative Type C continuing to exhibit imbalance during follow-up. Previous research also indicated that reduced thoracic flexibility and immediately postoperative coronal imbalance are risk factors for persistent postoperative coronal imbalance \u003csup\u003e[9]\u003c/sup\u003e. The above studies only considered the influencing factors of postoperative coronal imbalance from a single aspect, while our study comprehensively evaluated the clinical outcomes of different fusion strategies based on the patients' coronal pattern and poor thoracic compensatory ability. Our results showed that 17.1% of patients with poor thoracic compensatory ability and preoperative coronal Type C exhibited persistent coronal imbalance, compared to 2.3% with preoperative coronal Type A. Nearly 40% of patients with preoperative coronal Type C still had coronal imbalance after non-selective fusion surgery, whereas most patients were able to restore coronal balance at the last follow-up. All patients did not report significant pain, nor was there evidence of internal fixation loosening or breakage, negating the need for revision surgery. These findings indicated that patients with Type C coronal imbalance and poor thoracic compensatory ability may risk thoracic curve progression and suboptimal balance restoration after selective fusion. Therefore, surgical planning for such patients should consider selective fusion cautiously.\u003c/p\u003e \u003cp\u003eIn recent years, the postoperative quality of life for patients with adolescent idiopathic scoliosis has gained significant attention. Various assessment scales are used, with the Scoliosis Research Society's SRS-22 questionnaire being prominent. \u003csup\u003e[23,24]\u003c/sup\u003e This study focused on comparing postoperative quality of life in patients with preoperative coronal Type C AIS who underwent different fusion strategies. Findings indicated that patients who received non-selective fusion reported superior pain and self-image scores, while no significant differences were observed in psychological well-being, function, or satisfaction. These outcomes likely result from improved shoulder balance following thoracic curve fixation and fusion.\u003c/p\u003e\n\u003ch3\u003eLimitation\u003c/h3\u003e\n\u003cp\u003e This study had several limitations: (1) As a retrospective study, it may suffer from selection bias due to the loss of some patients\u0026rsquo; follow-up; (2) A large thoracic curve was deemed a factor for non-selective fusion, resulting in a relatively larger preoperative thoracic curve in the Type C2 group compared to the Type C1 group; (3) coronal Type B is very rare in Lenke 5C AIS. \u003csup\u003e[12]\u003c/sup\u003e In this study, none was classified into preoperative Type B group, which does not allow us to explore the discrepancies among Type A, B, and C groups.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study indicates that Lenke 5C AIS patients with preoperative coronal Type C and poor thoracic curve compensation are susceptible to thoracic curve progression and suboptimal coronal plane restoration following selective fusion. In such clinical scenarios, non-selective fusion achieves effective correction of the thoracic curve, improves patients\u0026rsquo; self-perception of body image, and avoids increasing the risk of distal decompensation\u0026mdash;without imposing significant restrictions on postoperative mobility. Surgeons should take caution when considering selective fusion in surgical planning for these patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThis study was approved by the Institutional Review Board (IRB) of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School (IRB No. 2021-398-01).\u0026nbsp;Freely given, informed consent was obtained from these patients in this study for all procedures undertaken and all data obtained.\u003c/p\u003e\n\u003cp\u003eThis study adhered to the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e：\u003c/strong\u003eThis work was supported by the Jiangsu Provincial Medical Innovation Center of Orthopedic Surgery (CXZX202214) and National Natural Science Foundation of China (82502981).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChunxiao Chen:\u0026nbsp;Conception and design, acquisition and data, writing, critical revision.\u003c/p\u003e\n\u003cp\u003eQiang Liu: Conception and design, acquisition and data, analysis and interpretation of data, critical revision.\u003c/p\u003e\n\u003cp\u003eJie Li: Conception and design, critical revision, supervision.\u003c/p\u003e\n\u003cp\u003eXiaodong Qin: acquisition and data, critical revision.\u003c/p\u003e\n\u003cp\u003eBenlong Shi: acquisition and data, critical revision.\u003c/p\u003e\n\u003cp\u003eSaihu Mao: acquisition and data, critical revision.\u003c/p\u003e\n\u003cp\u003eYong Qiu: Conception and design, critical revision.\u003c/p\u003e\n\u003cp\u003eZezhang Zhu: Conception and design, critical revision.\u003c/p\u003e\n\u003cp\u003eZhen Liu: Conception and design, critical revision, obtaining funding, supervision.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLARK RK, YASZAY B, BASTROM TP, et al. Adding Thoracic Fusion Levels in Lenke 5 Curves[J]. Spine, 2013, 38(2): 195-200. \u003c/li\u003e\n\u003cli\u003eYOSHIHARA H. Surgical Treatment of Lenke Type 5 Adolescent Idiopathic Scoliosis[J]. Spine, 2019, 44(13): E788-E799. \u003c/li\u003e\n\u003cli\u003eCAMPBELL RE, RUDIC T, HAFEY A, et al. Curve progression following selective and nonselective spinal fusion for adolescent idiopathic scoliosis: are selective fusions stable? [J]. Spine Deformity, 2024, 13(1): 177-187. \u003c/li\u003e\n\u003cli\u003eKWAN MK, CHIU CK, CHAN TS, et al. Flexibility assessment of the unfused thoracic segments above the \u0026ldquo;potential upper instrumented vertebrae\u0026rdquo; using the supine side bending radiographs in Lenke 5 and 6 curves for adolescent idiopathic scoliosis patients[J]. The Spine Journal, 2018, 18(1): 53-62. \u003c/li\u003e\n\u003cli\u003eCHANG SY, SON J, ZHENG GB, et al. Clinical outcomes of selective fusion for the thoracolumbar-lumbar curve in patients with Lenke type 6C adolescent idiopathic scoliosis: a preliminary study[J]. J Pediatr Orthop B, 2021, 30(3): 211-217. \u003c/li\u003e\n\u003cli\u003eMATSUMURA A, IWAMAE M, NAMIKAWA T, et al. Spontaneous Improvement of Postoperative Coronal Imbalance Following Selective Thoracolumbar-Lumbar Fusion in Lenke 5C Adolescent Idiopathic Scoliosis[J]. World Neurosurgery, 2021, 151: e241-e249. \u003c/li\u003e\n\u003cli\u003eSHETTY AP, SURESH S, AIYER SN, et al. Radiological factors affecting post-operative global coronal balance in Lenke 5 C scoliosis[J]. Journal of Spine Surgery, 2017, 3(4): 541-547. \u003c/li\u003e\n\u003cli\u003eYANG C, ZHAO Y, ZHAI X, et al. Coronal balance in idiopathic scoliosis: a radiological study after posterior fusion of thoracolumbar/lumbar curves (Lenke 5 or 6) [J]. European Spine Journal, 2016, 26(6): 1775-1781. \u003c/li\u003e\n\u003cli\u003eQIAO H, YAN K, LIAO B. Risk of coronal imbalance after posterior surgery for adolescent idiopathic scoliosis of type Lenke5C[J]. Current Medical Research and Opinion, 2024, 40(10): 1785-1791. \u003c/li\u003e\n\u003cli\u003eYANG X, HU B, SONG Y, et al. Coronal and sagittal balance in Lenke 5 AIS patients following posterior fusion: important role of the lowest instrument vertebrae selection[J]. BMC Musculoskeletal Disorders, 2018, 19(1). \u003c/li\u003e\n\u003cli\u003eZHANG T, SHU S, JING W, et al. Optimizing the fusion level for lenke 5C adolescent idiopathic scoliosis: is the S-line a validated and reproducible tool to predict coronal decompensation? [J]. European Spine Journal, 2021, 30(7): 1935-1942. \u003c/li\u003e\n\u003cli\u003eFANG Y, LI J, HU Z, et al. Postoperative Coronal Imbalance in Lenke 5C Adolescent Idiopathic Scoliosis: Evolution, Risk Factors, and Clinical Implications[J]. Neurospine, 2024, 21(3): 903-912. \u003c/li\u003e\n\u003cli\u003eKARADEMIR G, SARIYILMAZ K, DEMIREL M, et al. Does Thoracic Kyphosis Have any Importance in Selective Versus Nonselective Fusion Preference in Patients with Lenke Type 5C Adolescent Idiopathic Scoliosis? [J]. Turkish neurosurgery, 2023, 33: 118-125. \u003c/li\u003e\n\u003cli\u003eZHANG Y, LIN G, ZHANG J, et al. Radiographic evaluation of posterior selective thoracolumbar or lumbar fusion for moderate Lenke 5C curves[J]. Archives of Orthopaedic and Trauma Surgery, 2016, 137(1): 1-8. \u003c/li\u003e\n\u003cli\u003eTAUCHI R, KAWAKAMI N, OHARA T, et al. Sagittal Alignment Profile Following Selective Thoracolumbar/Lumbar Fusion in Patients with Lenke Type 5C Adolescent Idiopathic Scoliosis[J]. Spine, 2019, 44(17): 1193-1200. \u003c/li\u003e\n\u003cli\u003eLOUER C, YASZAY B, CROSS M, et al. Ten-Year Outcomes of Selective Fusions for Adolescent Idiopathic Scoliosis[J]. Journal of Bone and Joint Surgery, 2019, 101(9): 761-770. \u003c/li\u003e\n\u003cli\u003eCHEN K, CHEN Y, SHAO J, et al. Long-Term Follow-up of Posterior Selective Thoracolumbar/Lumbar Fusion in Patients with Lenke 5C Adolescent Idiopathic Scoliosis: An Analysis of 10-Year Outcomes[J]. Global Spine Journal, 2020, 12(5): 840-850. \u003c/li\u003e\n\u003cli\u003eDONG Y, WENG X, ZHAO H, et al. Lenke 5C Curves in Adolescent Idiopathic Scoliosis[J]. Neurosurgery, 2016, 78(3): 324-331. \u003c/li\u003e\n\u003cli\u003eSCHULTE TL, LILJENQVIST U, HIERHOLZER E, et al. Spontaneous Correction and Derotation of Secondary Curves After Selective Anterior Fusion of Idiopathic Scoliosis[J]. Spine, 2006, 31(3): 315-321. \u003c/li\u003e\n\u003cli\u003eZHANG Y, LIN G, WANG S, et al. Higher Flexibility and Better Immediate Spontaneous Correction May Not Gain Better Results for Nonstructural Thoracic Curve in Lenke 5C AIS Patients[J]. Spine, 2016, 41(22): 1731-1739. \u003c/li\u003e\n\u003cli\u003eLI M, FANG X, SUN Y, et al. Thoracic curve correction after posterior fusion and instrumentation of structural lumbar curves in patients with adolescent idiopathic scoliosis[J]. Archives of Orthopaedic and Trauma Surgery, 2011, 131(10): 1375-1381. \u003c/li\u003e\n\u003cli\u003eBAO H, ZHU F, LIU Z, et al. Coronal Curvature and Spinal Imbalance in Degenerative Lumbar Scoliosis[J]. Spine, 2014, 39(24): E1441-E1447. \u003c/li\u003e\n\u003cli\u003eKARAKAYA I, SISMANLAR SG, ATMACA H, et al. Outcome in early adolescent idiopathic scoliosis after deformity correction[J]. Journal of Pediatric Orthopaedics B, 2012, 21(4): 317-321. \u003c/li\u003e\n\u003cli\u003eFRANTZ\u0026Eacute;N A, SUOMINEN E N, SAARINEN A J, et al. Association Between Lenke Classification, The Extent of Lumbar Spinal Fusion, and Health-Related Quality of Life After Instrumented Spinal Fusion for Adolescent Idiopathic Scoliosis[J]. Spine, 2023, 48(17): 1216-1223.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e.\u0026nbsp;Comparison of baseline data between Group Type A and Group Type C\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA group\u003c/p\u003e\n \u003cp\u003e（n=43）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC group\u003c/p\u003e\n \u003cp\u003e（n=76）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge(yrs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.05\u0026plusmn;2.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.88\u0026plusmn;1.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.670\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGender (male: female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8:35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11:65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.555\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRisser sign\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.30\u0026plusmn;1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.44\u0026plusmn;0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.541\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eT curve flexibility (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43.10\u0026plusmn;10.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e44.62\u0026plusmn;9.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.487\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u0026nbsp;time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.30\u0026plusmn;15.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34.05\u0026plusmn;17.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.582\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 1: T curve flexibility: thoracic curve flexibility.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Comparison of Radiographic parameters between Coronal Type A and Type C1 groups in patients with selective fusion.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eType\u0026nbsp;A group\u003c/p\u003e\n \u003cp\u003e（n=43）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eType\u0026nbsp;C1\u0026nbsp;group\u003c/p\u003e\n \u003cp\u003e（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCBD (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.39\u0026plusmn;5.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.07\u0026plusmn;7.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePo-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.80\u0026plusmn;9.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.54\u0026plusmn;11.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.111\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.28\u0026plusmn;7.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.06\u0026plusmn;7.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eT curve (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.70\u0026plusmn;4.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.85\u0026plusmn;3.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.864\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePo-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.88\u0026plusmn;5.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.63\u0026plusmn;4.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.60\u0026plusmn;6.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.63\u0026plusmn;5.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.982\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTL/L curve (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49.28\u0026plusmn;8.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49.34\u0026plusmn;6.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.970\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePo-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.67\u0026plusmn;7.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.51\u0026plusmn;5.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.906\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.05\u0026plusmn;5.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.22\u0026plusmn;6.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.900\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eT-AVT (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.49\u0026plusmn;6.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.65\u0026plusmn;5.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePo-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.08\u0026plusmn;7.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.46\u0026plusmn;6.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.815\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.12\u0026plusmn;8.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.17\u0026plusmn;5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.686\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTL/L-AVT (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e47.01\u0026plusmn;8.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e51.86\u0026plusmn;8.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePo-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.89\u0026plusmn;5.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.03\u0026plusmn;6.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.930\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17.71\u0026plusmn;6.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.38\u0026plusmn;6.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.158\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFusion level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.53\u0026plusmn;0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.67\u0026plusmn;0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.530\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2: Pre-op: pre-operation; Po-op: post-operation; CBD: coronal balance distance; T curve: thoracic curve; TL/L curve: thoracolumbar/lumbar curve; T-AVT: thoracic apical vertebra translation; TL/L-AVT: thoracolumbar/lumbar apical vertebra translation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e. Comparison of postoperative complications between Coronal Type A and C1groups in patients with selective fusion\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eType\u0026nbsp;A group\u003c/p\u003e\n \u003cp\u003e（n=43）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eType\u0026nbsp;C1\u0026nbsp;group\u003c/p\u003e\n \u003cp\u003e（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProximal decompensation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9(20.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20(48.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDistal decompensation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5(11.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5(12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCoronal imbalance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePo-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7(16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16(39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1(2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7(17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3: Pre-op: pre-operation; Po-op: post-operation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e. Comparison of Radiographic parameters between Type C1 group and Type C2 group patients with preoperative Type C and poor thoracic compensatory ability.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eType C1\u0026nbsp;group\u003c/p\u003e\n \u003cp\u003e（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eType C2\u0026nbsp;group\u003c/p\u003e\n \u003cp\u003e（n=35）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCBD (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32.07\u0026plusmn;7.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.20\u0026plusmn;7.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.507\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePo-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.54\u0026plusmn;11.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.10\u0026plusmn;12.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.359\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.06\u0026plusmn;7.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14.72\u0026plusmn;6.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.910\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eT curve (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31.85\u0026plusmn;3.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e34.91\u0026plusmn;4.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePo-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.63\u0026plusmn;4.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.46\u0026plusmn;4.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.63\u0026plusmn;5.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.34\u0026plusmn;4.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTL/L curve (\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49.34\u0026plusmn;6.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e50.01\u0026plusmn;9.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.828\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePo-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.51\u0026plusmn;5.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.42\u0026plusmn;4.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16.22\u0026plusmn;6.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11.52\u0026plusmn;6.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eT-AVT (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15.65\u0026plusmn;5.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e21.19\u0026plusmn;6.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePo-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.46\u0026plusmn;6.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9.16\u0026plusmn;6.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12.17\u0026plusmn;5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.14\u0026plusmn;5.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTL/L-AVT (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePre-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e51.86\u0026plusmn;8.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49.55\u0026plusmn;8.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.253\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePo-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19.03\u0026plusmn;6.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22.73\u0026plusmn;6.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.037\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.38\u0026plusmn;6.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20.62\u0026plusmn;6.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.893\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 4: Pre-op: pre-operation; Po-op: post-operation; CBD: coronal balance distance; T flexibility: flexibility of thoracic curve; T curve: thoracic curve; TL/L curve: thoracolumbar/lumbar curve; T-AVT: thoracic apical vertebra translation; TL/L-AVT: thoracolumbar/lumbar apical vertebra translation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e5\u003c/strong\u003e. Comparison of postoperative complications between Type C1 group and Type C2 group patients with preoperative Type C and poor thoracic compensatory ability.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"489\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eType C1\u0026nbsp;group\u003c/p\u003e\n \u003cp\u003e（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eType C2\u0026nbsp;group\u003c/p\u003e\n \u003cp\u003e（n=35）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProximal decompensation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e20(48.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0(0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDistal decompensation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5(12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4(11.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCoronal imbalance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePo-op\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16(39.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13(37.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.866\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7(17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1(2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;Table 5:\u003c/p\u003e\n\u003cp\u003ePre-op: pre-operation; Po-op: post-operation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e6\u003c/strong\u003e. Comparison of SRS-22 scores between\u0026nbsp;Type C1 group and Type C2 group at 2-year follow-up.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eType C1\u0026nbsp;group\u003c/p\u003e\n \u003cp\u003e（n=41）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eType C2\u0026nbsp;group\u003c/p\u003e\n \u003cp\u003e（n=35）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.55\u0026plusmn;0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.88\u0026plusmn;0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFunction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.91\u0026plusmn;0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.13\u0026plusmn;0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.251\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eImage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.87\u0026plusmn;0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.33\u0026plusmn;0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.20\u0026plusmn;0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.33\u0026plusmn;0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.519\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSatisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.24\u0026plusmn;0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.38\u0026plusmn;0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.575\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"adolescent idiopathic scoliosis, Lenke 5C, thoracic progression, coronal imbalance, surgical strategy","lastPublishedDoi":"10.21203/rs.3.rs-8548158/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8548158/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo investigate the effect of preoperative coronal balance patterns on the clinical outcome of Lenke 5C patients with poor thoracic curve compensation ability following different fusion strategies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePoor thoracic compensatory ability was defined as a thoracic cobb angle between 15\u0026deg; and 25\u0026deg; on supine bending films. Coronal balance patterns were classified as Type A (coronal balance distance [CBD]\u0026lt;20mm), Type B (CBD\u0026thinsp;\u0026gt;\u0026thinsp;20 mm and C7 plumbline[C7PL] shifted to concave side of main curve), and Type C (CBD\u0026thinsp;\u0026gt;\u0026thinsp;20 mm and C7PL shifted to convex side of main curve), based on CBD and position of C7PL relative to main curve. Patients with preoperative Type C were classified into the Group Type C1(underwent selective fusion) and the Group Type C2(underwent non-selective fusion), and patients with preoperative Type A all underwent selective fusion surgery. Quality of life in preoperative Type C patients following different fusion strategies was assessed using the SRS-22 scale.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePatients with preoperative Type C coronal pattern and poor thoracic compensatory ability showed a higher likelihood of thoracic curve progression after selective fusion surgery compared to Type A patients (48.7% vs. 20.9%, P\u0026thinsp;=\u0026thinsp;0.007). In the Type A group, only 4.65% experienced thoracic curve progression exceeding 10\u0026deg;, while in the Type C1 group, this percentage was 21.95%. Additionally, at the last follow-up, 93.1% of Type A patients maintained good coronal balance, whereas 17.1% of Type C1 patients still had coronal imbalance. Type C2 patients who underwent non-selective fusion showed improved thoracic curvature from 34.86\u0026thinsp;\u0026plusmn;\u0026thinsp;4.64\u0026deg; to 11.14\u0026thinsp;\u0026plusmn;\u0026thinsp;4.30\u0026deg;, which was well maintained during follow-up. At the last follow-up, only 1 of 35 (2.8%) patients retained the Type C coronal pattern. The SRS-22 questionnaire showed that in Lenke 5C AIS patients with preoperative Type C, the Type C2 group had significantly higher pain (4.33\u0026plusmn;.51 vs. 3.87\u0026plusmn;.55, P\u0026thinsp;=\u0026thinsp;0.003) and self-image scores (4.88\u0026plusmn;.10 vs. 4.55\u0026plusmn;.50, P\u0026thinsp;=\u0026thinsp;0.020) compared to the Type C1 group.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFor Lenke 5C AIS patients exhibiting poor thoracic compensatory ability and preoperative Type C coronal imbalance, selective fusion demonstrated higher risks of proximal thoracic curve progression compared and inferior coronal balance restoration during follow-up. These findings suggest cautious consideration for preoperative coronal pattern and poor thoracic compensatory ability in Lenke 5C AIS patients when planning surgery strategies.\u003c/p\u003e","manuscriptTitle":"Optimizing surgical strategy in Lenke 5C AIS patients with poor thoracic compensatory ability: is there a role of coronal imbalance?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-05 17:21:00","doi":"10.21203/rs.3.rs-8548158/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-11T00:58:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T13:18:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-06T07:17:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T13:04:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"226496596430163758582982372562616200571","date":"2026-02-05T12:43:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9841239337868298548809000205984115135","date":"2026-02-03T23:46:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103962590427129734447372804559209586258","date":"2026-02-03T11:51:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"251402387886359660105898622790103196917","date":"2026-02-03T11:35:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-03T11:33:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-02T08:01:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-02T07:38:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Orthopaedic Surgery and Research","date":"2026-01-31T03:17:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-orthopaedic-surgery-and-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"josr","sideBox":"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)","snPcode":"13018","submissionUrl":"https://submission.nature.com/new-submission/13018/3","title":"Journal of Orthopaedic Surgery and Research","twitterHandle":"@MSKmedBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"472507c5-5bd8-49e8-ba2a-d2c37e4f1db5","owner":[],"postedDate":"February 5th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T16:01:29+00:00","versionOfRecord":{"articleIdentity":"rs-8548158","link":"https://doi.org/10.1186/s13018-026-06874-5","journal":{"identity":"journal-of-orthopaedic-surgery-and-research","isVorOnly":false,"title":"Journal of Orthopaedic Surgery and Research"},"publishedOn":"2026-04-27 15:58:21","publishedOnDateReadable":"April 27th, 2026"},"versionCreatedAt":"2026-02-05 17:21:00","video":"","vorDoi":"10.1186/s13018-026-06874-5","vorDoiUrl":"https://doi.org/10.1186/s13018-026-06874-5","workflowStages":[]},"version":"v1","identity":"rs-8548158","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8548158","identity":"rs-8548158","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}